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Obstetrics > Termination/Abortion > Flashcards

Termination/Abortion Flashcards

1
Q

How many pregnancies are result in abortion?

A

19%

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2
Q

What age range is highest for abortions?

A

20-24yo

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3
Q

When are abortions performed the most?

A

First trimester

63% <8wks

91% <13wks

Only 9% are after that

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4
Q

When is the legal limit for a 2nd trimester abortion in California?

A

23wks & 6days

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5
Q

Roe vs Wade

A

1st trimester (up to 14wks)

  • The state can’t interfere with a woman’s right to choose
  • decision b/w her & her provider
2nd trimester (14-24wks)
- The state CAN regulate abortion procedures fro safety reasons
3rd trimester ( >24wks)
- The state CAN prohibit abortions except when necessary
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6
Q

Hyde amendment

A

Forbids the use of federal funds for abortions except for Incest or life endangerment

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7
Q

What kind of restrictive laws are out there?

A
  • waiting periods
  • mandatory counseling
  • parental consent/notification
  • can’t be covered by private insurance
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8
Q

What is the leading research & policy organization committed to advancing sexual & reproductive health & rights in the US & globally?

A

Gutttmacher Institute

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9
Q

What are some falsehoods surrounding abortion?

A
  • long term mental health consequences
  • fetus feels pain
  • link to breast cancer
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10
Q

Random stuff

A
  • 51% of OBGYN residents are trained to do this
  • 32% of med schools offer 1 abortion lecture
  • complication rate lower than wisdom tooth removal overall
  • 2nd trimester abortions assoc w/ increased morbidity & mortality
    • maybe more social/emotional challenges
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11
Q

Describe pregnancy counseling

A
  • Be clear about the results: Test is positive, you’re pregnant
  • Allow time for pt to process
  • Don’t assume how pt will react
  • give basic information, non-directive
  • referL adoption, abortion, prenatal
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12
Q

What is involved in pregnancy dating & confirmation of IUP?

A
  1. LMP
  2. Quart Hcg
  3. Bimanual exam (fruit comparison)
    • lemon = 5-6wks
    • medium lemon = 7-8wks
    • grapefruit = 9-10wks
    • uterus out of pelvis @ 12wks
    • umbilicus = 20wks
  4. Ultrasound
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13
Q

What characteristics are involved w/ the Transvaginal probe

A
  1. Empty Bladder*
  2. Detects Earlier pregnancy*
  3. Better RESOLUTION , LESS DEPTH*
  4. More invasive*
  5. Probe 7.5-10mHz*
  6. Discriminatory level 1800-2300mIU/ml
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14
Q

What are the characteristics of a Transabdominal Probe?

A
  1. Full bladder*
  2. BETTER DEPTH, LESS RESOLUTION*
  3. Hard to see if <6wks*
  4. Less invasive*
  5. Probe 3-5mHz*
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15
Q

How to Locate an IUP

A

Measure 3 dimensions in 2 planes

  • longitudinal/length & Ht
  • transverse plane: width

Calculate the Mean Sac Diameter (MSD)
- MSD = L+W+H)/3

Calculate GA
- GA in days = MSD +30

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16
Q

What’s the diagnosis for a non-viable pregnancy?

A

Empty GS >25mm diameter

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17
Q

Early Preg Confirmation

Does not exclude ectopic

A

F: fundal, mid/upper uterus

E: elliptical/round in 2 views

E: Eccentric to the endometrial stripe

D: Decidual reaction (fluffy white cloud/ring around the sac

S: Size >4mm (soft criteria)

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18
Q

Other features of an IUP

A
  • yolk sac
  • BPD
  • CRL
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19
Q

What is the first US finding that confirms an IUP?

A

Yolk sac

  • round, echoic ring w/anechoic (dark center) inside the GS
  • Appears 5-6wks
  • MSD (mean sac diameter) = 5-10mm
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20
Q

When can cardiac activity be visualized on U/S?

A

Around 6 1/2wks

  • usually not assessed until 8wks at first prenatal visit
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21
Q

How to measure CRL

A

CRL = fetal pole

  • long axis (no limbs)
  • Calculate GA: CRL +42days
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22
Q

BPD measurement

A

> 12-14wks

  • inside to outside the skull
  • at level of the thalamus
  • No unchallenged/eye structures
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23
Q

When can you get a MAB?

A

10wks

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24
Q

When can you get a surgical abortion?

A

Before 13wks 6days

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25
Q

What is MAB?

A

Medical abortion (chemical)

Using medications NOT surgery

Mifepristone & Misoprostol (Cytotec)

26
Q

What are the benefits of MAB?

A
  • Can be done at home
  • sense of control over the process
  • safe & effective up to 70days
27
Q

Risks of MAB

A
  • Endometritis, infxn, hemorrhage (same as surgical)
  • teratogenic to ongoing pregnancy (so don’t change your mind)
  • may still need surgical aspiration
28
Q

Indications for MAB/1st trimester abortion

A

Mifepristone approved up to 49d (10wks)

Off-label after this

29
Q

Contraindications of MAB

A
  1. Ectopic pregnancy
  2. IUD — take it out first
  3. Chronic adrenal Faillure/Long term steroid therapy
  4. Hemorrhagic disorders, Anticoagulants
  5. Porphyrias (disorder from build up from blood products)
  6. Non-compliance
  7. Maybe chronic conditions like: HTN,DM, renal/hepatic/CV/cig smoking
30
Q

What are the clinician requirements for MAB?

A
  • Mifepristone Can only be prescribed by physicians
    BUT they can delegate another healthcare professional to administer the drug
  • make accurate assessment of GA
  • diagnose ectopic
  • surgical intervention if bleeding/incomplete abortion or make plans for care w/another provider
  • assure access to a hospital where they can get transfusions/resuscitation
31
Q

Clinician requirements (continued)

A
  • sign prescriber agreement w/ manufacturer of mifepristone
  • require pts read manufacturer’s medication guide & sign Pt agreement form
  • report
    • ongoing preg
    • serious events (hospitalization, infxn, bld transfusion
32
Q

What are the 2 regimens?

A
  1. FDA approved, manufacturer recommended
    - Mifepristone 600mg PO (—48hrs—> Misoprostol 400mcg PO
    - both given by physician so pt has to come back

*Not as effective

  1. Alternative regimen = evidence based
    - Mifepristone 200mg PO by clinician—24-72hrs–> Misoprostol 800mcg Buccal clinician or pt

*Most effective/cheaper

33
Q

Benefits of Evidence based Regimen

A
  • fewer ongoing pregnancies
  • cheaper
  • Fewer side effects
  • Convenience
  • greater efficacy: 50-63day gestation (7-9wks)
34
Q

How does Mifepristone work?

A

Antiprogestin

  • binds to progesterone receptors with greater affinity than progesterone itself
  • blocks action needed for placental attachment
35
Q

Initial visit

A
  1. Confirm pregnancy & GA
    - GA:LMP, Transvaginal U/S & Pelvic exam
    - Preg: serum/urine Hcg or U/S
    - U/S to r/o ectopic
  2. Counsel about options & Informed consent
  3. STI testing
  4. Blood typing/verification + RhoGAM
  5. Prophylactic abx to prevent endometritis
  6. Mifepristone given
  7. F/U
36
Q

What Abx are used for MAB prophylaxis ?

A

Azithromycin 500mg x 1
- can cause prolonged QT syndrome

Doxycycline 100mg BID x7days

37
Q

What are some side effects of Mifepristone?

A
  1. GI: n/v/d
  2. Abd pain & cramps
  3. Excessive vaginally bleeding, 8-17d
  4. HA, dizziness, fatigue
38
Q

Pt education

A
  • written & verbal instructions about sxs, adverse effects and what to do if significant pain, bleeding
  • NSAID/narcotic analgesia
  • Emergency phone numbers given
  • how to take it
39
Q

Follow Up visit

A

2wks

  • to confirm expulsion
    • via pelvic exam, Hx, or transvaginal ultrasound
  • provide contraception
40
Q

What are some Complications of MAB?

A
  • Hemorrhage (may need to r/o if incomplete)
  • Infxn 0.016%
  • Incomplete abortion
    • incomplete expulsion
    • ongoing pregnancy
  • unrecognized ectopic pregnancy
41
Q

Should get an eval if

A
  • fever, chills, body aches
  • excessive/prolonged bleeding
  • moderate -severe pelvic pain more than a day after expulsion
  • purulent vaginal discharge
42
Q

What determines efficacy of MAB?

A
  1. Gestational duration (49-70days/7-10wks)
  2. Route of administration & does of MISOPROSTOL
  3. Parity
    • rate of success lower with increasing parity & if had one before
43
Q

What is the most commonly used method of pregnancy termination in the U.S.?

A

Surgical abortion/TAB

44
Q

What are the techniques of TAB?

A
  • D&E
  • sharp cutterage
  • suction cutterage
45
Q

When is TAB performed?

A

7wks-12/13wks 6days

46
Q

What are the benefits of a TAB/surgical abortion?

A
  • 1 visit only
  • safe & effective for FIRST TRIMESTER abortions
  • complication rate 0-3%
  • 98-99 % effective
47
Q

Risks of surgical abortion/TAB

A
  1. Endometritis
  2. Life threatening infections (more w/ TABs)
  3. Hemorrhage
    • d/t cervical laceration or uterine injury (instrumentation)
48
Q

What are the indications for TAB?

A
  1. (VEA)- very early abortion
    • up to 6wks after +preg test
      - NO visualization of sac required if ectopic unlikely
      - manual vacuum/electric aspiration
      - tissue examined while pt in room
      - serial Hcg testing done if not confirmed
49
Q

TAB initial visit

A
  1. Confirm pregnancy & GA
  2. Counsel about options & informed consent
  3. STI testing
  4. Contraception counseling
  5. Bld typing + RhoGAM
  6. Pre-dose w/ NSAID, anxiolytics, and prophylactic Abx
    • Ibuprofen + Ativan
  7. Sterile technique
  8. Products of conception verified while pt in room
  9. Post-op monitoring 30min
  10. D/C with meds: NSAIDS, Methergine, Doxycycline & contraception
  11. F/U in 2-4wks
50
Q

What are the return precautions for TAB?

A

If sxs have not resolved within 1wk or if normal menses has not returned in 6wks

  • no sex/tampons for 2wks
  • most complications happen within a wk
51
Q

What are possible complications of a TAB?

A
  1. Hemorrhage
    - retained tissue
    - uterine perforation
    - retained tissue
    - uterine atony
  2. infxn
  3. Incomplete abortion
52
Q

Indications for 2nd trimester abortions

A

Elective pregnancy termination
- Delay in dx or obtaining abortion

Fetal anomaly
Maternal illness (severe preeclampsia)
PROM

53
Q

Protocol of 2nd trimester abortions

A

Preprocedure prep
- dilate cervix w/ Laminaría

Anesthesia/Abx
- paracervicla block/IV conscious sedation

Procedure (focusing on D&E)

Utterotonics
Assessment of retaine dproducts
Discharge
F/U in 2wks

54
Q

Complications of 2nd trimester abortions

A 
Retained products of conception
Cervical laceration
Uterine perforation
Infxn
Hemorrhage
55
Q

What are the most common signs of early pregnancy loss?

A 
Vaginal bleeding
Abd cramping
Pelvic/back pain
Passing tissue
Constitutional: fever, chills, muscle aches
56
Q

Diagnoses of early pregnancy loss

A
  • One of the following:
    1. US confirmation of embryonic gestation or fetal demise in uterus w/ falling Hcg levels
    2. Absence of previously seen IUP on US
    3. Tissue exam confirming expulsion
57
Q

EPL Management

A
  1. Expectant- watch & wait
  2. Medical mgt - MAB meds: Mifepristone+ Miso or just Miso
    - Methotrexate if ectopic
    - Need to F/U with Ultrasound
  3. Aspiration: no F/U
58
Q

What should ALWAYS be considered w/ First trimester bleeding?

A

Ectopic pregnancy

6-8wks

59
Q

How is ectopic pregnancy diagnoses confirmed?

A

Serial HCGs & Ultrasounds

60
Q

What should be suspected with a + preg test w/o US evidence?

A

Ectopic

61
Q

What is the treatment for ectopic preg?

A

Methotrexate w/ serial Hcg levels

62
Q

LMP should be considered a vital sign for which age group?

A

9-55yo

Obstetrics (6 decks)

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